Is Bariatric Surgery Safe in Cirrhotics?

Implication for health policy/practice/research/medical education: Bariatric surgery may help improve outcomes in obese cirrhotic patients who have been denied evaluation for liver transplanta-tion primarily because of weight. which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Obesity is associated with an increase in mortality and primary graft nonfunction after liver transplantation (LT) (1). Weight loss is recommended for obese patients in need of LT. Diet, exercise, or medications are rarely successful. Conversely, bariatric surgery can allow patients to achieve significant and sustained weight loss, leading to improvement of obesity-associated comorbidities such as hyperlipidemia and diabetes (2-4). Bariatric surgery may be useful in cirrhotics needing LT who were denied evaluation primarily because of weight. We examined the medical literature concerning the safety and efficacy of bariatric surgery in cirrhotics by conducting a literature search using MD Consult, Cochrane, Ovid, and Medline with keywords " cirrhosis, " " bariatric, " and " obesity surgery. " Studies in English through Janu-ary 2012 were included. We recorded information about demographics, type of bariatric surgery, and surgical outcome. Three articles were identified, giving a combined total of 44 patients with cirrhosis undergoing bariatric surgery (5-7). Laparoscopic surgery was performed in two studies (Dallal et al., Takata et al.). The third (Brolin et al) employed open approaches (Table). The mean age at surgery was 49.5 years. The average BMI before surgery was 52.5 kg/m 2. Where reported, all patients were Child class A or B. Most of the patients (32, 73%) were found to have cirrhosis unexpectedly during surgery. 27 patients underwent laparoscopic Roux-en-Y gastric bypass (RYGB), seven patients underwent open RYGB, 9 patients underwent laparoscopic sleeve gastrectomy, and 1 patient underwent jejunoileal bypass. 3 patients who underwent laparoscopic banding were excluded from one of the studies. 21 patients (48%) were followed at least 9 months with an average percentage of excess weight loss (EWL) of 54.2%. Dallal et al. reported that the mean operative time was 4 hours, while Takata et al. reported a mean operative time of 2.4 hours. Operative time was not mentioned in Brolin et al. There were no intraoperative deaths; one patient died during the perioperative period from acute hepatic decompensation with hepatorenal syndrome. Postopera-tive complications occurred in 14 patients (32%) (Table).